TABLE OF CONTENTS. This community health needs assessment was commissioned by Codman Square Health Center in 2013/14. All rights reserved.

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In partnership with TABLE OF CONTENTS EXECUTIVE SUMMARY... I BACKGROUND... 1 Overview of Codman Square Health Center... 1 Purpose and Scope of Assessment... 1 METHODS... 3 Study Approach and Community
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In partnership with TABLE OF CONTENTS EXECUTIVE SUMMARY... I BACKGROUND... 1 Overview of Codman Square Health Center... 1 Purpose and Scope of Assessment... 1 METHODS... 3 Study Approach and Community Engagement Process... 3 Quantitative Data... 4 Qualitative Data... 4 Codman Square Health Center Staff Survey... 5 Limitations... 7 FINDINGS... 8 COMMUNITY SOCIAL AND ECONOMIC CONTEXT... 8 Demographic Diversity... 8 Income, Poverty, and Employment Education Housing and Transportation Violence and Neighborhood Safety COMMUNITY HEALTH ISSUES Perceived Community Health Status Mortality and Morbidity Chronic Diseases and Related Risk Factors Mental and Behavioral Health Sexual Health, Teenage Pregnancy, and Birth Outcomes Health Care Access and Utilization COMMUNITY ASSETS AND PROGRAMS COMMUNITY SUGGESTIONS FOR FUTURE PROGRAMS, SERVICES, AND INITIATIVES KEY THEMES AND CONCLUSIONS This community health needs assessment was commissioned by Codman Square Health Center in 2013/14. All rights reserved. Codman Square Health Center Community Health Needs Assessment March 2014 EXECUTIVE SUMMARY Introduction Codman Square Health Center (CSHC) is a community-based, outpatient health care and multi-service center located in the Boston neighborhood of Dorchester, MA. In June 2013, CSHC contracted with Health Resources in Action (www.hria.org), a non-profit public health organization in Boston, to conduct its community health needs assessment (CHNA) to ensure that it is addressing the most pressing health concerns among its general patient population and among Dorchester residents who live in close proximity to the health center. In addition to meeting the Health Resources and Services Administration (HRSA) health center program requirements (Section 330(k)(2) and Section 330(k)(3)(J) of the PHS Act), the overarching goals of the 2013 CSHC Community Health Needs Assessment (CHNA) were to: Identify the health-related needs and assets of CSHC s service area; and Determine where there are gaps and potential opportunities for CSHC to address these needs. To this end, the CHNA report provides an overview of the key findings of the community health needs assessment, which explores a range of health behaviors and outcomes, social and economic issues, health care access, and gaps and strengths of existing resources and services. Community Health Needs Assessment Methods The community health needs assessment utilized a participatory, collaborative approach to look at health in its broadest context. The assessment process included synthesizing existing data on social, economic, and health indicators in Dorchester as well as among CSHC s patient population and conducting a staff survey completed by 133 clinical and non-clinical health center staff. Additionally the assessment process included conducting a community dialogue, four focus groups, and eleven interviews to identify the perceived health needs of the community, challenges to access services, current community strengths and assets, and opportunities for action. Participants represented different audiences, including CHSC board members, staff and patients, the faith community, the civic community, government officials, educational leaders, social service providers, health care providers, parents, and other community members, among others. Ultimately, the qualitative research engaged over 70participants. Key Findings The following provides a brief overview of key findings that emerged from this assessment: Community Social and Economic Context Demographic Diversity: Nearly every participant highlighted diversity as a key strength of Dorchester, including the range of age, cultural, ethnic, linguistic, and economic groups that characterize the neighborhood. o o We are an amalgam of cultures and income diversity. Focus group participant According to the Bureau of Primary Health Care Uniform Data System (UDS), CSHC served a total of 20,643 patients in 2012, over half of whom resided in Dorchester (53.6%). Quantitative data illustrate that the majority of Boston s and CSHC s patient population was between the ages of 18 and 64 years (64.0% and 64.7%, respectively) o Blacks represent the largest racial/ethnic group in N. and S. Dorchester (41.7% and 47.3%), followed by Hispanic/Latinos in N. Dorchester (20.0%) and Whites in S. Dorchester (29.0%). Similarly, a majority of CSHC s patient population self-identified as Black (88.0%). Income, Poverty, and Employment: Several participants spoke of the economic challenges facing residents in the community, including underemployment. Economic data confirm that considerable Codman Square Health Center Community Health Needs Assessment March 2014 i Percent proportions of neighborhood residents are poor. N. Dorchester (26%) had a higher proportion of families living below the federal poverty line compared to the city overall (23%). Educational Attainment: Quantitative data show high educational attainment among Boston s adult residents aged 25 years and older, with 44% having earned a college degree or more; whereas less than 25% of Dorchester residents have a college degree or higher. Housing and Transportation: The lack of affordable housing was identified as an important issue in the community. In Boston, over 40% of renters contribute 35% or more of their income to housing costs, compared to 34.9% of homeowners. Furthermore, while some viewed the transportation in the area as an asset, others identified challenges with transportation. The Boston Indicator Project reports that more than one out of five workers residing in Dorchester who lack access to MBTA subways or commuter lines spend an hour or more getting to work each day. Violence and Neighborhood Safety: Concerns regarding neighborhood safety were a prominent theme across interviews and focus groups. N. and S. Dorchester reported an annual homicide rate of 17.9 and 19.4 homicides per 100,000 residents, respectively more than double the city-wide rate (7.9 homicides per 100,000 residents). Community Health Issues Perceived Community Health Status: Over half of all CSHC staff described the community s health as fair/poor (57.2%). Among all staff, diabetes, mental health, and obesity were viewed as the top health issues of concern for both the community at large (nearly 60% of all staff) and CSHC s patient population (nearly 40% of clinical staff). Mortality and Morbidity: Quantitative data indicate that cancer is the leading cause of death in Boston, followed by heart and Figure 1: Perceived Health Status of Community Served by All Staff, 2013 cerebrovascular disease (including stroke). A similar pattern is seen in the neighborhoods of N. and S. Dorchester. Examining CSHC clinical data reported to the Uniform Data Reporting System show the percent of adult medical patients (18 years of age and older) with hypertension has nearly doubled over the past three years from 13.9% in 2010 to 26.0% in Chronic Diseases and Related Risk Factors: Similar to staff survey results, chronic conditions and their associated lifestyle behaviors were also top of mind concerns for focus group and interview participants, namely diabetes, obesity, and asthma. o In 2010, N. and S. Dorchester had a higher proportion of obese adults (31.0% and 24.0%, respectively) compared to Boston overall (21.0%). Participants also noted the barriers that residents face in addressing obesity, particularly access to healthy food and physical activity. o In 2010, N. and S. Dorchester also had a higher proportion of adult residents with diabetes (8.0% and 7.0%, respectively) compared to Boston (6.0%). o Participants also observed high rates of asthma in their community, which they described as exacerbated by poor air quality and housing conditions. In 2010, the prevalence of adult asthma was particularly high in N. Dorchester (18%) and well above that of Boston (11%). Additionally, children under age five in N. Dorchester (39.0 per 1,000) and S. Dorchester (32.8 per 1,000) 50% 40% 30% 20% 10% 0% 5.9% 4.2% 32.8% 45.4% 11.8% Excellent Very Good Good Fair Poor DATA SOURCE: Codman Square Health Center Community Health Needs Assessment Staff Survey, 2013 Codman Square Health Center Community Health Needs Assessment March 2014 ii experienced higher rates of visits to the Emergency Department due to asthma, compared to children citywide (22.9 per 1,000). Mental and Behavioral Health: Mental health emerged as a pressing issue among participants as well who described mental health conditions ranging from stress and anxiety to depression and Post Traumatic Stress Disorder, which were often related to community violence and substance abuse. o Depressive symptoms affect both youth and adults in Boston. N. and S. Dorchester had the same proportion of adults reporting persistent sadness (feeling sad, blue, or depressed 15 or more of the past 30 days) as Boston (9%). In 2011, nearly 25% of Boston youth reported feeling sad or hopeless; however, this percentage has decreased since o The majority of participants primarily expressed concerns regarding the effects of residents witnessing violence in their neighborhoods and low perceptions of neighborhood safety. Rates of emergency department visits for nonfatal stabbing or gunshot wounds are higher in N. and S. Dorchester (1.6 and 2.1 visits per 1,000 residents, respectively) compared to Boston (0.9 visits per 1,000 residents). o Drug use was often noted in the context of mental health as a means of self-medication. According to the 2010 BBRFSS and 2011 YRBS, 23.0% of adults and 17.0% of youth indicated that they participated in excessive alcohol consumption. In 2010,the death rate due to substance abuse in N. and S. Dorchester (23.4 and 23.1 deaths per 100,000 population) was lower than that of Boston (33.9 deaths per 100,000 population). Health Care Access and Utilization: Challenges regarding access to care were raised in almost every focus group and interview. Barriers included: health insurance coverage and cost, navigating the complex healthcare system, and culturally sensitive care. o o o o o o In 2012, a majority of CSHC s patient population used its medical services (94.5%), followed by enabling services, and vision services (30.4% and 20.4%, respectively). Staff were most satisfied with public transportation to health services and overall health/medical services and least satisfied with substance abuse treatment services and interpreter services. According to clinical staff survey respondents, insurance coverage, long wait times for appointments, and language barriers were the primary challenges for patients to access care, followed by lack of transportation and cost of care. The challenges to accessing care faced by the under- and uninsured was a common theme raised by assessment participants. Challenges ranged from the inability to afford prescription medications to insufficient coverage for substance abuse treatment. In addition to health insurance coverage, several participants described the difficulties of navigating an increasingly complex and fragmented healthcare system. Challenges included scheduling appointments in a timely manner (e.g., waiting six weeks for an appointment) and finding a primary care physician who is accepting new patients. Assessment participants frequently noted the barriers posed by cultural and linguistic differences between patients and providers. Immigrants were identified as a particularly vulnerable population. Lack of access to care; without a job there s no health insurance. Without health insurance there s no health care, there s poor health. Interview participant Community Assets and Programs Assessment participants were asked to identify their communities strengths and assets. The following key themes emerged from that discussion: Community Cohesion and Activism: Dorchester was described as a neighborhood with a strong sense of community. Participants characterized residents as passionate and invested in the Codman Square Health Center Community Health Needs Assessment March 2014 iii community. They shared how community activists have been able to successfully mobilize residents to advocate for and achieve change. Local Organizations and Businesses: Assessment participants also indicated that there are numerous resources available to residents in the community. They described the recreational facilities and green spaces, seasonal farmers markets, area hospitals and neighborhood health centers, and the multitude of faith based organizations as community assets. Community Suggestions for Future Programs, Services, and Initiatives Assessment participants shared their suggestions around future We have a slew of resources available, but it s about communicating the programming and services: availability of those resources. And the Participants emphasized the importance of improving the built way you get that out is through outreach, environment in order to address health concerns. Specific areas to bring people into the inner folds. of note included food access, green space, physical infrastructure, Community Dialogue Participant and housing. Limited employment opportunities in the community were viewed as a root cause for health issues, ranging from violence and drug abuse to teen pregnancy and obesity. Therefore creating job opportunities and supporting workforce development was encouraged to align skills with employment, particularly among youth. While participants noted that numerous organizations serve the community, they also indicated that better integration and coordination of services was needed. Community members would like to see increased collaboration across sectors and among key stakeholders in Dorchester. Strengthening community outreach and engagement was recommended by participants in order to improve access to existing resources and overcome cultural and linguistic barriers. Participants strongly encouraged employing community health workers and patient navigators to hit the pavement and connect residents to services. Many participants mentioned providing health education to the community that focuses on prevention and promoting a healthy lifestyle. Specific topics of interest included healthy eating, explaining the affordable care act, and preventing chronic diseases. Key Themes and Conclusions Several overarching themes emerged from this synthesis of data, including: The social, economic, and physical context of the community underscores all aspects of daily life for residents, although the community also possesses several strengths. Chronic diseases and related lifestyle behaviors were viewed as important community health issues which disproportionately affect minority and low-income residents. Mental and behavioral health emerged as a pressing issue for the community, for which there is a lack of services. Despite the expansion of healthcare coverage, insurance status, a complex healthcare system, and cultural and linguistic differences prevent residents from receiving care. Future opportunities were identified for expansion of CSHC s work in the community and its partnerships with organizations. As CSHC moves forward, it can leverage the assets of the community to improve the health of residents in Dorchester and its patient population. Codman Square Health Center Community Health Needs Assessment March 2014 iv BACKGROUND Overview of Codman Square Health Center Codman Square Health Center (CSHC) is a community-based, outpatient health care and multi-service center located in the Boston neighborhood of Dorchester, MA. Founded in 1979, CSHC s mission is to serve as a resource for improving the physical, mental, and social well-being of the community. Today, CSHC has a staff of over 280 multi-lingual and multi-cultural expert clinicians and employees. CSHC serves over 20,000 patients each year and provides comprehensive services including primary care, urgent care, dental care, eye care, behavioral health, public health, fiscal health, fitness/wellness, and youth programming through various internal and external partnerships. CSHC is a Federally Qualified Health Center (FQHC) and receives federal support through its designation as a Section 330 community health center. Purpose and Scope of Assessment In June 2013, CSHC contracted Health Resources in Action (www.hria.org), a non-profit public health organization in Boston, to conduct its community health needs assessment (CHNA). This report describes the process and findings from this effort. In addition to meeting the Health Resources and Services Administration (HRSA) health center program requirements (Section 330(k)(2) and Section 330(k)(3)(J) of the PHS Act), the CHNA process was undertaken to achieve the following overarching goals: To identify the health-related needs and assets of CSHC s service area; and To determine gaps and potential opportunities for CSHC to address these needs. Definition of the Community Served by Codman Square Health Center CSHC has undertaken a community health needs assessment to ensure that it is addressing the most pressing health concerns among residents in Dorchester, who are in close proximity to the health center, as well as its general patient population. Figure 2outlines the boundaries of North (02121 and 02125) and South Dorchester (02122 and 02124), which comprise the neighborhood of Dorchester, as defined by the Boston Public Health Commission. CHSC is physically located in zip code Codman Square Health Center Community Health Needs Assessment March Figure 2: Geographic Focus Area of CSHC CHNA DATA SOURCE: Accessed from on September 19, 2013 Codman Square Health Center Community Health Needs Assessment March METHODS The following section describes how data for the community health needs assessment was compiled and analyzed, as well as the broader lens used to guide this process. Specifically, the CHNA defines health in the broadest sense and recognizes that numerous factors at multiple levels impact a community s health from lifestyle behaviors (e.g., diet and exercise), to clinical care (e.g. access to medical services), to social and economic factors (e.g., employment opportunities), to the physical environment (e.g., air quality). The beginning discussion of this section discusses the larger social determinants of health framework which helped guide this overarching process. Study Approach and Community Engagement Process So that the process was informed by diverse perspectives, the community health needs assessment employed a participatory approach, when possible. This type of approach helps guide the research methods and questions so that they are salient to the community as well as aids in building support and buy-in at the community level for both the assessment study and subsequent planning processes. As part of this effort, CSHC sought input from its Board of Directors at multiple stages of the assessment study. CSHC s Board is comprised of community leaders and health center staff, including Dorchester residents. A majority live and/or work in the service area (80%) and are users of the health center (66%). Over half of board members are Black (53.3%) and male (60.0%).Length of service of board members ranges from 3-37 years. Areas of expertise include: academics, business/it, community leadership, human resources, urban ministry, environmental, finance, health care, legal, senior issues, and social work. The Board participated in two formal meetings to brainstorm a list of potential stakeholders and provide feedback on preliminary findings. A CHNA subcommittee of board members was engaged in weekly conference calls and s throughout assessment planning and implementation, finalized the list of potential stakeholders for interviews, provided suggestions on who to engage, and gave feedback on the stakeholder and focus group guides. Social Determinants of Health It is important to recognize that multiple factors have an impact on health a
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